Download Defining Features of Chronic Critical Illness

Role of LTACH in Chronic Critical Illness in the Elderly
Thiruvoipati Nanda Kumar, MD, FACP, MRCP (UK & IRE)
Vibra Hospital of Northern California
Clinical Associate Professor University of California at Davis
Redding CA. 96001 USA
[email protected]
Abstract:
Long term acute care hospitals (LTACH) have become an integral part of the
healthcare continuum since they were established in the United States in 1999 [1].
Many elderly patients admitted to intensive care units survive an acute episode of
illness but do not recover fully and develop chronic critical illness (CCI) [2].
These patients have been stabilized in short term acute care hospitals with
completion of diagnostic workup and transferred to LTACHs. Elderly patients who
have CCI form an important group of patients admitted to LTACHs. LTACHs are
organized to provide multidisciplinary management that includes complex medical
therapies such as ventilator weaning and dialysis, intravenous therapies like total
parental nutrition, complex wound care, and rehabilitative services including
physical, occupational and speech therapies. Consistent with high disease burden of
comorbidities and poor outcome in the subset of patients with CCI, palliative care
should become an essential component of the post acute care continuum (PACC) [9].
LTACHs play a pivotal role in transitioning these patients across the PACC. Details
regarding organization of LTACHs, management of patients with special reference to
CCI and perspectives for future advances are discussed in this chapter.
Keywords:
Long term acute care hospital (LTACH), chronic critical illness (CCI), post acute care
continuum (PACC), elderly, ventilator, outcomes
Introduction:
Advances in medicine and intensive care have led to many elderly patients surviving
acute phase of illness, leading to a state of chronic critical illness requiring
specialized treatments for a prolonged period of time. Since their creation in the
United States in 1999, LTACHs have become an integral part of the post acute health
care continuum, serving medically complex patients for a period initially envisaged
as more than 25 days [1,6]. While LTACHs typically admitted patients who were
difficult to wean from mechanical ventilation, they now cater to a wider range of
patients with complex medical conditions in the setting of chronic comorbidities like
congestive heart failure, end stage renal disease, diabetes mellitus type II, and
chronic difficult to heal wounds. Elderly patients with chronic critical illness are an
important and challenging subset of patients admitted to the long-term acute care
hospitals, after stabilization in intensive care units in short term acute care hospitals
(STACH) [3].
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Chronic critical illness is a devastating condition resulting many times from
respiratory failure with difficulty to liberate from mechanical ventilation and
characterized by prolonged debility, multi organ dysfunction, physical and cognitive
impairments [2]. A course complicated by intercurrent illnesses, poor outcomes,
and high mortality are a hallmark of chronic critical illness in the elderly. LTACHs
are organized to provide such multidisciplinary specialized care. Being the first
destination in post acute care, long term acute care hospitals play an important role
in defining the aggressiveness and level of care and arranging appropriate transition
of care as these patients still remain with significant comorbidities and cognitive
and functional impairments.
This chapter deals with details regarding organization of LTACHs and management
of chronic critically ill patients, including incorporation of palliative care
approaches. Defining aggressiveness of care, directives regarding cardio pulmonary
resuscitation, discharge disposition to the next level of care are addressed. These
issues will need further refinement as advances in medicine including pharmacotherapeutics, genomic health and outcomes research enhance our understanding
that can be incorporated into our decision making.
LTACH: Organization and Services
Patients admitted to acute hospitals and intensive care units suffer a wide variety of
acute severe illnesses such as sepsis, respiratory failure with sepsis, pneumonia,
COPD, cardiac, neurological, hepatic, renal, gastrointestinal, oncological illnesses,
trauma, post operative states, etc. While they survive the acute phase, recovery is
incomplete, and they require complex specialized inpatient management for
prolonged period of time. About ten percent of patients with acute respiratory
failure become chronically critically ill [3]. LTACHs have come to be established to
provide such level of specialized multidisciplinary care at a cost lower than that of
intensive care units. Coordination of expertise specially geared to treat such patients
with complex comorbidities is accomplished by a multi disciplinary team. Patients
requiring weaning from prolonged mechanical ventilation and those with conditions
requiring inpatient care for about twenty-five days are usually admitted to the
LTACHs. Amongst the elderly population, many suffer from acute illnesses including
sepsis, severe pneumonia, endocarditis, vascular events, post operative
complications, trauma in the setting of chronic disease burden such as CHF, COPD,
end stage renal disease (ESRD) on dialysis, immunocompromised states,
malnutrition, neurological and musculoskeletal impairments, etc. These patients
have completed diagnostic workup and require comprehensive medical
management that may include mechanical ventilation, dialysis, intravenous
therapies for antibiotics, total parental nutrition, complex wound care management
including excisional debridement, and rehabilitative services including physical,
occupational therapies. They do not however require the level of monitoring and
diagnostic services available in intensive care units, and can be provided at a lower
cost in LTACHs.
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High intensity monitoring and treatment targeted at their acute illness and
decompensation with meticulous attention to other chronic illnesses is required to
lead to improved outcomes in terms of medical management and improvements in
functional capacity. LTACHs provide an opportunity to discharge patients at an early
stage from intensive care units [8]. While the need for twenty five days of stay was a
main determinant for LTACH admissions in the past, experience gained so far in
terms of quality of care, outcomes and cost are leading to refinements in the patient
selection criteria.
There are two types of locations for long term acute care hospitals. Some are free
standing, separate hospitals while others operate as a specialized unit within the
hospital called “hospital in hospital” set up. Free standing hospitals are developed to
provide a full gamut of services and multidisciplinary coordination. They have
enough bed strength to support provision of those services. Hospital within hospital
units provide benefits in facilitating early transition to the next level of care while
having the advantage of acute hospital ancillary services and other consultative
services at the doorstep. Short term acute hospital operations are benefited by
freeing of ICU beds, better utilization of available space by leasing to LTACHs, and
providing ancillary diagnostic services [5].
Criteria for LTACH admissions
The majority of LTACH admissions are Medicare beneficiaries. The following criteria
have to be met for admission to LTACHs: Patients must be screened prior to
admission regarding their appropriateness for admission to LTACH in terms of their
medical complexity and requirement of inpatient services for a longer period and
should be validated within 48 hours of admission [1,8].
a) Daily physician visits and review of progress with availability of necessary
consulting physicians at the bedside on a timely basis.
b) Regular review and evaluation of the need for continued care in the LTACH
with appropriate discharge disposition if patient does not meet criteria for
care in LTACH.
c) An individual treatment plan must be formulated for each patient by the
interdisciplinary health care team including physicians.
d) An average length of stay more than 25 days was required for all Medicare
patients. There is a welcome shift in emphasizing the need for complexity of
medical care with multidisciplinary team approach rather than adherence to
25-day length of stay as the main criteria. Adjustments in financial
reimbursements will however follow.
As the criteria for requirement of average length of stay undergoes revision,
financial reimbursements may be impacted. But greater number of medically
complex patients that would benefit from intensity of care and multidisciplinary
approach offered in LTACHs could be cared for and have better outcomes. The
heterogeneity of patient population and the smaller number of patients admitted to
LTACHs makes it difficulty to study the outcomes comprehensively. But continued
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attention to quality metrics and refinements are essential. The quality metrics
measured and reported include ventilator weaning, wound healing and prevention
of pressure ulcers, avoidance of STACH readmissions, catheter related blood stream
infections, mortality and patient safety indicators [5].
As the treatment progresses in LTACHs, the interdisciplinary team plays an
important role in consolidating the progress materialized and charting a course for
further transition to home or appropriate venue of care, establishing future advance
directives on appropriate level of care and coordination of post acute services.
The above characteristics of LTACHs and the delineation of services provided makes
them an obvious venue for treating chronic critically ill elderly patients who survive
catastrophic severe illnesses.
Chronic Critical Illness
While advances in critical care have resulted in improved survival from acute
illness, it has led to a large group of patients who are chronically critically ill.
These patients have difficulty weaning from mechanical ventilation, require high
intensity therapeutic, rehabilitative services and suffer from chronic debility and
cognitive and physical decline punctuated by intercurrent illnesses. The number of
these patients is increasing and constitutes about ten percent of patients with
respiratory failure admitted to intensive care units with mechanical ventilation.
Protracted recovery period and poor outcomes are a hallmark of this group. More
than fifty percent of such patients are above 65 years. There is a fifty percent
mortality at the end of first year and only ten percent are living at home at the end
of one year, albeit with some impairment [2,3,6]. The incidence of chronic critical
illness has doubled with each decade consistent with the increase of aging
population and availability of critical care services. The overall annual healthcare
cost of chronic critical illness has exceeded twenty billion dollars and is steadily
increasing [2,8].
The clinical phenotype is easily recognizable at the bedside by the constellation of
clinical features and context. But the heterogeneity of clinical conditions that lead to
chronic critical illness as well as varied presentations render difficulties in arriving
at a precise clinical definition.
Defining Features of Chronic Critical Illness
While a strict definition is elusive, patients considered to have the syndrome of
chronic critical illness in various studies have included: [2,3,6,8]
1. Respiratory criteria in the setting of
2. Chronic pathophysiological state
1. Respiratory criteria:
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a) Respiratory failure with a difficulty to wean requiring prolonged
mechanical ventilation for at least 21 consecutive days for at least 6 hours a
day. Patients requiring mechanical ventilation for at least 96 hours and an
ICU length of stay for at least 21 days.
b) Patients with mechanical ventilation for at least 96 hours with a
tracheostomy placement when done for a condition other than head, neck or
face disease. Tracheostomy placement indicates a clinical judgment that
patient survived from acute episode with no impending signs of death but
unable to liberate from mechanical ventilation. Tracheostomy placement is
considered a turning point in the progression of course from acute to chronic
critical illness [3,9].
c) Patients who required at least ten days of mechanical ventilation and not
expected to die or be liberated from mechanical ventilation in the next 72
hours where also considered to have chronic critical illness in some studies.
d) Patients with respiratory failure transferred to LTACHs are generally
considered to have entered the stage of chronic critical illness, as the initial
purpose of creation of LTACHs was to serve patients that require prolonged
services.
2. Chronic Patho-Physiological State:
The patients that progress to chronic critical illness form a variety of
conditions have a chronic pathophysiological state with persistent
inflammation that seems to diminish the physiological reserves and impairs
repair [2,6,11]. It comprises elements of multi-organ dysfunction
encompassing various systems as follows:
 Cardiac
 Renal
 Hepatic
 Endocrinopathy with hormonal dysregulation including loss of
pulsatile anterior pituitary hormone secretion, stress hyperglycemia,
 Severe functional decline associated with axonal neuropathy
 Decreased muscle mass with increased adiposity
 Anasarca with hypoprotienemia
 Increased susceptibility to infections and sepsis with resistant
organisms
 Encephalopathy manifesting as varying degrees of delirium and
cognitive impairment
 Wounds escalated by immobilization including nutritional deficiency,
incontinence, infection.
 Malnutrition
Limitations in the use of Respiratory Failure in defining Chronic Critical Illness
a) Patients who are medically complex requiring prolonged medical
management share pathophysiological features characteristic of chronic
critical illness but do not need intubation with mechanical ventilation or
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tracheostomy. Examples of such patients include those with severe COPD and
respiratory failure requiring high flow oxygen and non invasive ventilation
for prolonged periods, patients requiring longer term inotropes, left
ventricular assist devices, and those elderly patients with sepsis and chronic
comorbidities [3]. This group includes patients who survived medical or
surgical illness that did not require mechanical ventilation but required
prolonged inpatient care and form a significant population of patients
admitted to LTACHs. These patients are considered to have chronic critical
illness.
b) Patients requiring mechanical ventilation for neuro degenerative disorders
or myopathic conditions without the comorbid burden pathognomonic of
chronic critical illness. Examples are amyotrophic lateral sclerosis, muscular
dystrophies. Such patients do not share the pathophysiological substrate and
are not considered to have chronic critical illness.
Clinical Features: Course and Outcomes of Chronic Critical Illness
The clinical picture of elderly patient with chronic critical illness is characterized by
recovery from acute critical illness with ventilator dependence, debility, delirium,
severe functional decline, in the setting of multiple comorbidities and
immunocompromised states. Accordingly, they have ongoing complex medical
therapies continued from short term acute hospitals or intensive care units that
include mechanical ventilation, dialysis, intravenous therapies for antibiotics or
total parental nutrition or complex wound care. The course is complicated by
infections, sepsis, and intercurrent illnesses involving other organ systems.
While many patients are unable to express their symptoms due to their physical and
mental condition, they suffer from significant symptoms both physical and
psychological. These include pain, dyspnea, anxiety, unsatisfied hunger and thirst.
The other sign and symptoms are related to the precipitating acute illness, pre
existing comorbidities, inter current illness and complications during the course of
treatment [9]. Hence they encompass multiple organ systems and vary from patient
to patient due to the heterogeneity of these conditions [9,13]. Following is a list of
conditions involving patients with chronic critical illness:
 Respiratory: complications associated with ventilation, decanulation,
atelectasis, pneumonia, acute COPD exacerbation.
 Cardiac: CHF, cardiomyopathy, cardiac arrhythmias, acute coronary
syndromes.
 Renal: acute kidney injury, chronic kidney disease, complications of
dialysis
 Neuromuscular: axonal polyneuropathy, myopathy.
 Neuropsychological: delirium, restlessness, anxiety, psychomotor
agitation, post traumatic stress disorder.
 Gastrointestinal: hemorrhage, ileus, diarrhea, complications of
parenteral and enteral nutrition, C. Difficile Colitis.
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
Infections: pneumonia, bacteremia without definite source, catheter
related blood stream infections, gram negative infections, methicillin
resistant staphylococcal aureus, vancomycin resistant enterococci and
other multi drug resistant organisms. C. Difficile colitis.

Metabolic/Nutritional: malnutrition, anasarca, decreased lean body
mass, increased adiposity, stress hyperglycemia, hypothalamic
pituitary adrenal hormonal dysregulation, increased bone resorption,
vitamin D deficiency, electrolyte imbalance [6].
The above conditions require strict attention in terms of management and
prevention. However improving the general condition, well being and emotional
state of the patient by diligent attention to nutrition, exercise and mobility, fluid
electrolyte balance, emotional support, sleep, and avoidance of drug side effects and
toxicities should be the corner stone of management of these patients [2,10].
Clinical Course and Outcome
Consistent with the complexity and multiplicity of problems involved with the care
of chronically critically ill elderly patients, the course is complicated by heavy
symptom burden, poor outcomes and extensive resource utilization. About ten
percent of patients who require mechanical ventilation in the ICUs become
chronically critically ill. While generalizations of outcome are difficult due to the
heterogeneity of patient conditions and features of different venues, about 30-50
percent are weaned from mechanical ventilation [2]. The duration of time taken for
ventilator liberation varies depending on the diagnosis and condition of patients
from 16-37 days [2]. Patients who cannot be weaned in 60 days are unlikely to
wean. A significant number of patients with chronic critical illness successfully
weaned from ventilator continue to have poor prognosis and are burdened by
comorbid conditions with multi organ dysfunction, intercurrent illnesses,
immunocompromised states with poor functional status, and cognitive impairment.
There is a high risk of death in three months and fifty percent of patients are dead
by the end of one year. Only ten percent of patients are living at home after one year
[7,9].
Elderly patients with multi organ dysfunction in general have poor prognosis [12].
It is not age alone, but advancing age with comorbidities and limitations in
functional status adversely affect survival and prognosis.
Pro Vent score was developed as a prognostic model to predict mortality. Four
factors are taken into consideration: 1) age above 50 years 2) platelet count less
than 150, 000 microliters 3) need for vasopressors 4) need for dialysis are
calculated on twenty first day of mechanical ventilation. Presence of all four factors
was associated with 100 percent mortality at one year [3,4,6]. Absence of all four
factors was associated with 80 percent survival at one year. Physical and cognitive
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impairments are severe in chronically critically ill in elderly compared to acute
phase. Understanding outcomes, modulating treatment and decisions regarding
aggressiveness of care should focus not only on mortality, but effects on functional
status and quality of life.
Venues of care: LTACH and beyond:
LTACHs have been in existence since 1999 to serve the needs of medically complex
patients that require prolonged hospitalization [8]. Patients requiring liberation
from mechanical ventilation constituted an important group of patients admitted to
LTACHs. Patients are transferred from short term acute hospitals to provide care
adapted to the special needs of chronically critically ill patients at a low cost
environment [8]. STACHs were able to discharge patients to LTACHs earlier. This
enables STACHs to utilize ICU beds for other patients who are in need for acute
critical care illness. In LTACHs, results are often optimized in an environment of
multidisciplinary approach geared to treat this group of patients with lower levels
of monitoring and cost [15]. LTACHs are not uniformly distributed in different states
within the United States and there is a geographical conglomeration in some states
while absence of LTACHS in other areas [3,5,6]. Such patients are treated by
extended length of stay in the ICUs and transferred to other venues in due course. At
the end of optimizing treatment based on cardio pulmonary and functional status,
patients are discharged to lower levels of care. Depending on their care
requirements, they are discharged to home with adequate care giver support and
home health services. assisted living facilities, skilled nursing facilities, and in
patient rehabilitation facilities. The majority of these patients were living at home
prior to their acute critical illness that culminated in chronic critical illness [9].
Patients and families have to grapple with complexities of adapting to a completely
different discharge disposition. Movement to and fro between different venues of
acute and post acute care is an important feature in chronically critically ill elderly
[6]. Costs of health care are increasing, estimated to have crossed 20 billion
annually, while the number of patients with chronic critical illness is also increasing.
Decision making including aspects of palliative care
Physicians and members of health care team should have a clear understanding and
knowledge of outcomes. Attempts to understand patient wishes and preferences
regarding cardio pulmonary resuscitation and life saving therapies should be made
earlier in the course [9]. Symptom relief and palliative care should play an
important role [6]. Understanding and explaining principles of palliative care to
families is important to root out the misconception that palliative care is giving up.
It is striving for the best quality of life appropriate to the condition with full
understanding of the risks and benefits involved in chosen therapies. Physicians and
members of health care team should be knowledgeable and recognize that chronic
critical illness is a separate pathophysiological entity with different clinical
connotations and outcome compared to acute phase of illness. This highlights the
need to chart a different course in CCI compared to those with acute critical illness
[6]. Individual therapeutic decisions should however align with the patient’s overall
wishes and goals. Education of health care providers is of paramount importance in
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improving understanding and decision making by patients and family members who
carry a heavy burden [16]. Families need information regarding estimates of
survival, functional impairments and needs of care giving. In the proportion of
patients who only survive to suffer and die over several months, early institution of
do not resuscitate status and palliative measures are meaningful if consistent with
patient’s wishes.
Perspectives for the Future
Measures to improve better understanding and treatment of acute critical illnesses
like sepsis, acute respiratory distress syndrome, acute kidney injury will decrease
chronic critical illness [11].
Improvements in antibiotic stewardship, prevention of nosocomial infections,
catheter associated blood stream infections and new therapies now under
investigational phase for C. Difficile Colitis will all play an important role.
Knowledge of chronic critical illness is not widely apparent among the spectrum of
health care providers. With increasing aging population, availability and utilization
of critical care services world wide, chronic critical illness should become part of
curriculum in medical education [7]. Knowledge of palliative care and adequate
deployment where needed should be encouraged.
Although LTACHs are established in the United States, the experiences and
perspectives gained in LTACHs could be adapted to suit different locations
worldwide.
Genetic studies hold further promise in being able to understand longevity,
susceptibility in response to certain infections and diseases that may be heritable
[14]. Individuals may have targeted therapies appropriate to their genetic studies.
Identification of specific biochemical markers in chronic critical illness may play a
role in stratification of patients with chronic critical illness.
Increased use of non invasive ventilation at early stages to prevent endotracheal
intubation may decrease complications and the number of patients progressing to
chronic critical illness. Improvements to non invasive ventilation like delivery via
helmet interface may enhance tolerability, compliance and effectiveness with
diminished air leak.
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Acknowledgements
I gratefully acknowledge the help received from Vibra Hospital of Northern
California for the insights gained in the management of LTACH patients, Dr Edward
Zawada for sharing experiences regarding CCI from a long, enlightened career, Ms
Debbie Monroe (Dignity Hospital) for help with literature search, and
Dr Simrann Birk for assisting in the preparation of this manuscript.
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